Health inspection·June 17, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and interview the facility failed to provide oral care in a timely manner. This affected one (Resident #1) of three residents reviewed for activities of daily living. The census was 139. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 11/13/20. Diagnoses included schizoaffective disorder, type two diabetes, morbid obesity, unspecified dementia. Resident #1 required assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/26/24, revealed Resident #1 had intact cognition and was dependent for bed mobility, transfers, and oral care. Review of the Plan of care dated 01/19/20 revealed Resident #1 had impaired dentition and was at risk for oral problems related to broken, loose teeth with interventions including to provide oral care at least daily and/or more frequently as needed. Review of the oral care task sheet for Resident #1 dated 05/20/24 through 06/17/24 revealed on 05/22/24, 05/24/24, 05/25/24, 05/26/24, 05/27/24, 05/30/24, 06/03/24, 06/03/24, 06/06/24, 06/08/24, and 06/13/24 there was no documentation oral care was completed. Interview on 06/17/24 at 8:41 A.M. with Resident #1 revealed he did not receive oral care daily and he had not received oral care this morning. Observation of Resident #1 revealed his teeth were not clean and he was not shaved. Interview on 06/17/24 at 8:59 A.M. with State tested Nurse Assistant (STNA) #204 revealed he did not complete Resident #1's oral care because third shift staff were responsible for providing oral care. Record review and interview on 06/17/24 at 11:13 A.M. with Assistant Director of Nursing (ADON) #208 and ADON #210 verified oral care was not documented as completed for Resident #1 on 05/22/24, 05/24/24, 05/25/24, 05/26/24, 05/27/24, 05/30/24, 06/03/24, 06/03/24, 06/06/24, 06/08/24, and 06/13/24. There was documentation that oral care was provided on 06/17/24 at 9:32 A.M. A follow up interview on 06/17/24 at 11:18 A.M. with STNA #204 verified that he had not completed oral care for Resident #1 on 06/17/24. Observation of Resident #1's oral cavity on 06/17/24 at 11:23 A.M. with ADON #208 and ADON #210 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365134 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Ridge Nursing & Rehabilitation Center 721 Hickory St Akron, OH 44303 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)